‘A system that is struggling’: understanding health protection resilience in England during the COVID-19 pandemic through the experiences of local health protection responders

Background Local health protection systems play a crucial role in infectious disease prevention and control and were critical to COVID-19 pandemic responses. Despite this vital function, few studies have explored the lived experience of health protection responders managing COVID-19. We provide new insights by examining how COVID-19 shaped infectious disease prevention and control in local health protection systems in England. Methods Semi-structured interviews were conducted with twenty local health protection responders from three contrasting local authority areas, and Public Health England (PHE) health protection teams, in England between June 2021 - March 2022. Participants were from: PHE health protection teams (n=6); local authority public health teams (n=5); local authority Public Protection Services (n=7); and local authority commissioned Infection Prevention and Control Teams (n=2). Data were analysed using reflexive thematic analysis. Results First, participants acknowledged the pandemic caused an unprecedented workload and disruption to local health protection service delivery. There was not enough capacity within existing local health protection systems to manage the increased workload. PHE health protection teams therefore transferred some COVID-19 related health protection tasks to other staff, mainly those employed by local authorities. Second, health protection responders highlighted how COVID-19 drew attention to the weaknesses in local health protection systems already stressed by reduced funding in the years leading up to the pandemic. Injecting money into the COVID-19 response did not completely overcome former losses in specialist health protection workforce. Third, health protection responders described how pandemic management raised the profile of public health, especially infectious disease prevention and control. Managing COVID-19 strengthened collaborative working, resulting in enhanced capacity of local health protection systems at the time. Conclusion The COVID-19 pandemic challenged the public health preparedness of all countries. Health protection responders in this study also expressed many challenges. There was insufficient resilience in these local health protection systems and an inability to scale up the specialist health protection workforce, as required in a pandemic situation. The UK needs to learn from the pandemic experience by acknowledging and addressing the challenges faced by local health protection responders so that it can more effectively respond to future threats. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-024-10651-7.


Supplementary File 2: Interview schedule 1. Interview schedule for participants with a direct role in Health Protection
I am interested in finding out how your role has changed over time, and the way in which local authority health protection systems respond to infectious diseases might have changed over time.I will ask a number of questions around this subject.The interview can be stopped at any time if you do not wish to continue.There are no right or wrong answers, I just want to find out what you think and what your experiences and practices have been.

Roles and Responsibilities
Background to role Collaboration with other organisations?
Ask about other organisations, people or policies relevant to their role • Are there any people or organisations that we have not yet discussed who you think might be relevant to your role?
Bring the interview to a conclusion • Is there anything else we haven't discussed that might be important to understanding how austerity or COVID-19 might have shaped the way infectious diseases are managed by local authority public health or Environmental Health services?

Interview schedule for participants with an indirect role in Health Protection (e.g. Health Protection managerial responsibilities)
I am interested in finding out how your role has changed over time, and the way in which local authority health protection systems respond to infectious diseases might have changed over time.I will ask a number of questions around this subject.The interview can be stopped at any time if you do not wish to continue.There are no right or wrong answers, I just want to find out what you think and what your experiences and practices have been.

Roles and Responsibilities
Background to role Bring the interview to a conclusion • Is there anything else we haven't discussed that might be important to understanding how budget cuts or COVID-19 might have shaped the way infectious diseases are managed by health protection services?

Following the Interview
Thank the interviewee for taking part in the interview and ask if they are happy to have his/her interview included in the research.Debriefing forms will then be given out.

Specific role in the prevention and management of Gastrointestinal infections
• Can you tell me about your role in the local authority?• How long have you been working in this role?• Have you had any previous roles in this local authority?Can you tell me about them?• Can you tell me what your roles and responsibilities are? • Can you describe what you might do as part of that role in a typical day? • Can you tell me about other things your role might involve?Specific role in prevention and management of infectious diseases • Can you tell me what role you have in the prevention of infectious diseases?• Can you tell me what role you have in the management of infectious diseases?• Can you tell me what organisations you work with to fulfil these roles and responsibilities?• Can you tell me what role you have

in the prevention of gastrointestinal infections? • Can you tell me what role you have in the management of gastrointestinal infections? • Can you tell me what organisations you work with to fulfil these roles and responsibilities? Impact of local budget cuts and local authority restructuring on local authority health protection
Prompts ask for examples of changes in, e.g.Can you describe to me what impact (if any) local budget cuts and local authority restructuring have had on the management or prevention of gastrointestinal infections by Environmental health/Public health services (use whichever appropriate to role) Prompts ask for examples of changes in, e.g.If you personally haven't had changes in your roles and responsibilities can you describe to me what impact (if any) COVID-19 have had on local authority public health services/environmental health services (delete as appropriate) as a whole?Prompts ask for examples of changes in, e.g.
• Can you describe to me what impact (if any) local budget cuts and local authority restructuring have had on the management or prevention of infectious diseases by Environmental health/Public health services (use whichever appropriate to role)

of local budget cuts and local authority restructuring on local authority health protection services
• Have you had any previous roles in this local authority?Can you tell me about them?• Can you tell me what your roles and responsibilities are? • Can you describe what you might do as part of that role in a typical day? • Can you tell me about other things your role might involve?Relevance of role to health protection services • Can you tell me how your role relates to public health services and environmental health services in your local authority?• Can you tell me how this role has changed over time?Impact

Impact of local budget cuts and local authority restructuring on the prevention and management of infectious diseases such as Gastrointestinal infections •
Can you tell me if or how the resources you have available for the prevention and management of infectious diseases (such as gastrointestinal infections) might have changed over the course of your time in [name of local authority]?• Can you tell me what has been behind the changes in these resources over time?Prompts ask for examples of changes in, e.g.

Problems and Programs for health protection services in the local authority •
Can you tell me about the major problems that you are most occupied with which are relevant to health protection at the moment?•Canyou tell me about the major programs that you are most occupied with which are relevant to health protection at the moment?

Impact of COVID-19 on local authority health protection
• Can you describe to me any changes in your roles and responsibilities since the COVID-19 pandemic?• Can you describe to me what impact (if any) COVID-19 have had on local authority public health or environmental health services as a whole?Prompts ask for examples of changes in, e.g.

Ask about other organisations, people or policies relevant to their role •
Are there any people or organisations that we have not yet discussed who you think might be relevant to your role?